PowerPoint 演示文稿 - AAO Annual Session · 2018/5/1 2 Treatment of BP with LA Lingual appliances have been applied to treat BP for 20 years Effective for levelling and enhanced

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Invisible orthodontic appliances:

clear aligner vs. individual lingual system——Treatment of bimaxillary protrusion

Outline

1. Two types of invisible orthodontics

2. Bimaxillary Protrusion (BP)

3. Treatment of BP with Lingual Appliances ( eBrace，China)

4. Treatment of BP with Clear Aligners (Invisalign G6, USA &

Angelalign A7, China)

5. Clear aligner VS. Individual lingual appliance

Invisible Orthodontics

In recent years, invisible orthodontics has been increasingly popular

➢ Popularity[1]

[1]Align Technology, Inc. – Q4 and Year End 2017 Financial Results

The current two types of invisible orthodontics

Clear Aligner(CA)

Bimaxillary Protrusion(BP)

Protrusive upper and lower anterior teeth

Class I or nearly Class I molar relationship

Normal occlusion but dissatisfactory convex profile

Extraction of four premolars

Retraction of anterior teeth with enhanced anchorage

Treatment of BP

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Treatment of BP with LA

Lingual appliances have been applied to treat BP for 20 years

Effective for levelling and enhanced posterior anchorage

High efficiency for space closure and short duration

[1] Tai K, Park J H, Tanino M, et al. J Clin Orthod, 2012,46(12):739-746, 754.[2] Tamamura N, Kuroda S, Sugawara Y, et al. The Angle Orthodontist, 2009,79(3):577-584.[3] Kawakami M, Miyawaki S, Noguchi H, et al. Angle Orthod, 2004,74(5):715-719.[4] Kurz C. Am J Orthod Dentofacial Orthop, 1997,112(4):357-363.[5] Jing Xuan, Wu Xiuping, Wang Jun. International J Stomatology, 2018,45(1): 100-105.

CAD/CAMConventional Self-ligating brackets

Individual LA

eBrace(China)

Straight or bended archwire Maxillary bite platePersonalized designs

Case Report

F, 21Y; CC: protrusive lips

Pre-Tx

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Pre-Tx

Problem List

• Angle Cl I• Skeletal Cl I, average angle• Bimaxillary protrusion• Moderate crowding

• Lower midline shifts to the left• Impacted 38,48

Extract 14, 24, 35, 45

Individual lingual appliance (eBrace)

Tx PlanSet-up

eBrace (China)

Tx 1 Mo Tx 3 Mo

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Tx 5 Mo Tx 12 Mo

Tx 14 Mo Tx 15 Mo

Tx 17 Mo 有没有debonding 的结束合面像？如果没有，可以不放合面像

Tx 17 Mo

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Pre-tx

Post-tx

Set-up

Good match

Case Summary

The eBrace individual lingual appliance is highly efficient for

treatment of BP through anterior retraction after extraction

TADs are used only for the upper, and we have extracted the

lower 5s instead of 4s since the lower molars have very strong

anchorage

Case Report

F, 31Y; CC: protrusive lips

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Pre-Tx Pre-Tx

Mesurement Normal Pre-Tx

SNA (°) 83.1 77.9

SNB (°) 79.7 72.2

ANB (°) 3.5 5.7

SN-MP (°) 32.9 43.8

S-Go/N-Me (%) 65.9 59.3

U1-L1 (°) 127.0 120.7

U1-SN (°) 104.6 92.3

FMIA (°) 57.0 42.9

UL-E (mm) 1.8 1.3

LL-E (mm) 2.7 5.1

Pre-Tx

Skeletal ClⅡHigh angle

Problem List

Angle clⅡ,sub

Problem List

Moderate crowding

Problem List

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Lower midline shifts to the right

Problem List

Extract 15, 25, 35

Finish with full Cl II on the right and Cl I on the left

Tx Plan

Difficulty：torque control of upper incisors

Key point ：

Tx Plan

Ask for 7°additional labial crown torque for the upper incisors

Set-up

eBrace (China)

Tx 4 Mo Tx 7 Mo

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M

F

Tx 7 Mo

Labial crown torque

Tx 13 Mo

Tx 13 Mo Finish 18 Mo

Finish 18 Mo Finish 18 Mo

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Finish 18 Mo

Retention 6 Mo

Retention 6 Mo

Improved chin curvature and profile！

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Case Summary

This is not a BP but a skeletal Cl II camouflage case, which is

more difficult with higher demand for the torque control of upper

incisors

The individual LA itself is fairly good for anterior torque control ,

thanks to the “ribbon” archwire

Additional pre-torque can be added to the upper incisors in the

set-up if necessary

Only a small number of BP cases treated with clear aligners has been

reported

According to our experiences

• The less crowding, the more difficult , due to more sagittal teeth movement

needed

• The more molar mesialization, the more difficult

Treatment of BP with CA

[1] Giancotti A, Greco M, Mampieri G. Prog Orthod, 2006,7(1):32-43.[2] Choi N, Park Y, Jo Y, et al. American Journal of Orthodontics and Dentofacial Orthopedics, 2009,135(5):671-681.[3] Yutong P, Jie T, et al. Journal of Practical Stomatology, 2012,28(05):659-661.

Invisalign G6

Invisalign (Align Technology, USA) has developed the G6 scheme for

premolar extraction and maximum anchorage cases, with molar

mesialization less than 2mm

G6 is supposed to facilitate bodily molar mesialization with optimized

attachments and staging

Multi-teeth

Unit

Aligner pre-anchorage

Optimal retraction attachments

Optimal anchorage attachments

SmartForce SmartStage

Invisalign G6

Case Report

F, 26Y, CC: protrusive lips

Pre-Tx

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Pre-Tx

• Angle ClⅡ• Skeletal ClⅡ，high

angle• Bimaxillary protrusion

• Severe crowding• Excessive overjet• Impacted 38&48

Problem List

Extract 14, 24, 34&44

Tx Plan

Retract front teeth to reduce lip protrusion Invisalign, G6

G6 attachments not applicable for 26&27 due to short crowns; therefore conventional attachments placed instead

Tx 6 Mo

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Tx 10 Mo Tx 16 Mo

Going on with refinement

18 Mo (R0 Finish) Tx 18 Mo

Tx 18 Mo

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Case Summary

When treating BP with the Invisalign G6 , molars are supposed

to be mesialized less than 2mm; therefore, TADs are usually

needed for the upper arch

Even with G6 , molar tilting is almost unavoidable, which requires

correction in the refinement stage; therefore, the whole Tx

duration is usually more than 2.5 years, longer than LA

Angelalign A7

Angelalign (China) has also introduced the A7 scheme for treatment

of BP cases with 4 premolars extraction and maximum anchorage

A7 uses vertical rectangular attachments on posterior teeth,

characterized by dual vertical rectangular attachments(DVA) on first

molars to facilitate bodily mesialization

Angelalign

A7

Bodily movement of canine

Anchorage control Torque control

Vertical control of posterior teeth

Dual vertical rectangular attachments(DVA)

greater moment

Pre-anchorage

(molar distal tipping first before mesialization)

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F, 32Y; CC：protrusive profile

Case ReportPre-Tx

Pre-Tx

measurement normal Pre-Tx

SNA (°) 83.1±4 87.8

SNB (°) 79.7±3 90.5

ANB (°) 3.5±2 -2.7

SN-MP (°) 32.9±4 22.9

S-Go/N-Me (%) 65.9±4 74.4

U1-L1 (°) 127.0±9 111.0

U1-NA（mm） 4.0±2 9.1

U1-SN (°) 104.6±6 124.5

L1-NB（mm） 4.0±2 9.5

L1-MP（°） 90.0±6.5 101.2

FMA（°） 25.0±6 17.8

FMIA (°) 57.0±7 61.2

UL-E (mm) 2.0±2 2.0

LL-E (mm) 3.0±2 4.7

Pre-Tx

Angle Cl I

Problem List

Skeletal Class III

Low angle

Horizontal growthpattern

Problem List

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Extract 14, 24, 34& 44

Retract the anterior teeth to reduce lip protrusion

Tx Plan

Angelalign, A7

Tx 3 Mo Tx 8 Mo

Tx 15 Mo

Going on with refinement

21 Mo (R0 finish)

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21 Mo (R0 finish) 21 Mo (R0 finish)

measurement normal Pre-tx R1

SNA (°) 83.1±4 87.8 89.0↑

SNB (°) 79.7±3 90.5 90.0

ANB (°) 3.5±2 -2.7 -1.0↑

SN-MP (°) 32.9±4 22.9 19.0↓

S-Go/N-Me (%) 65.9±4 74.4 78.1↑

U1-L1 (°) 127.0±9 111.0 133.4↑

U1-NA（mm） 4.0±2 9.1 5.5↓

U1-SN (°) 104.6±6 124.5 114.5↓

L1-NB（mm） 4.0±2 9.5 2. ↓

L1-MP（°） 90.0±6.5 101.2 87.5↓

FMA（°） 25.0±6 17.8 14.3↓

FMIA (°) 57.0±7 61.2 78.5↑

UL-E (mm) 2.0±2 2.0 0↓

LL-E (mm) 3.0±2 4.7 -0.5↓

21 Mo (R0 finish)

Case Summary

When treating BP with Angelalign A7, TADs are still needed for

the upper arch if maximum anchorage is needed

The results and duration for treating BP extraction cases using

Angelalign A7 or Invisalign G6 are similar

Different from Invisalign G6’s optimized attachments, Angelalign

A7 mainly uses conventional attachments, which may be more

reliable however less comfortable

Clear aligner VS. Individual lingual appliance

Share in common

Esthetic → The outstanding advantage of these two types of appliances

lies in “INVISIBLE”

Digital → Customized, with visible and more accurate outcomes

[1] Nedwed V, Miethke RR. Motivation, J Orofac Orthop, 2005, 66(2): 162-173.[2] Meier B, Wiemer KB, Miethke RR. J Orofac Orthop, 2003,64(5): 352-358.[3] Fritz U, Diedrich P, Wiechmann D. J Orofac Orthop, 2002, 63(3): 227-233.

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Differences

I. Almost VS. Complete invisible

CA is less invisible compared with LA, due to attachments and the possible

white spot lesions on the labial surface

However, it seems that CA can also meet the esthetic requirements of the

majority of patients.

[1] van der Veen MH, Attin R, Schwestka-Polly R, et al. Eur J Oral Sci, 2010, 118(3): 298-303.

Clear aligner VS. Individual lingual appliance II. Efficacy of tooth movement

CA

molar distalization(88%), intrusion(33%-37%),

torque(49%-51%), rotation(19%-43%)…

LA

High efficacy in maxillary expansion, bite-opening, en-masse

retraction of anterior teeth

✓ LA is more efficient for treating BP extraction cases

[1]Rossini G, Parrini S, Castroflorio T, et al. Angle Orthod, 2015, 85(5): 881-889.[2] George RD, Hirani S. J Orthod, 2013, 40 Suppl 1: S8-13.

III. Quality of Life

✓ CA has a higher quality of life

Pain Speech Mastication

Clear aligner Short recovery No effect No effect

Lingual applianceMore severe

Long recovery Negative effect Negative effect

[1]Shalish M, Cooper-Kazaz R, Ivgi I, et al. Eur J Orthod, 2012, 34(6): 724-730. [2] Khattab TZ, Farah H, Al-Sabbagh R, et al..Angle Orthod, 2013, 83(3): 519-526.

IV. Periodontal health

Periodontal health during orthodontic treatment mainly depends on oral

hygienic condition

LA is hard for cleaning and therefore affects periodontal health

CA is removable and much easier for cleaning

Direct comparison of CA vs. LA: CA wins!

✓ CA is a better choice for patients with periodontal or oral hygiene

problems

[1] Talic NF.. Saudi Dent J. 2011,23(2):55-59.[2]Lombardo L, et al. Prog Orthod. 2013;14:28.[3] Miethke RR, Brauner K. J Orofac Orthop. 2007,68(3):223-231.

V. Temporomandibular joints

CA is a kind of splint appliance with certain thickness.

Bite plates of front teeth brackets in LA can separate the upper and

lower teeth and eliminate occlusal interferences

✓ Both may have beneficial effects on TMJ problems

VI. For orthognathic surgery

Both can be used for orthognathic surgery cases

The labial surface of teeth may need temporary bonding of brackets or

buttons for post-surgery elastics, which requires informed consent from

the patient when choosing to use CA or LA

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VII. Duration, chair-side time and visit frequency

LA seems to have a shorter average duration compared with CA

CA cases have an obvious reduction in chair-side time and visit frequency

✓ For who want to finish earlier, LA is suggested; for who cannot visit

monthly, CA is better

[1] Gu J, Tang JS, Skulski B, et al. Am J Orthod Dentofacial Orthop, 2017, 151(2): 259-266. [2] Buschang PH, Shaw SG, Ross M, et al. Angle Orthod, 2014, 84(3): 391-396.

VIII. Compliance

The treatment effect and duration of CA largely rely on the patients’

compliance, since the aligners are removable.

Invisalign teenage aligners have compliance indicators, though the validity

of which is doubtful

✓ CA has higher demand for the patient’s compliance

[1] Tuncay OC, Bowman SJ, Nicozisis JL, et al. J Clin Orthod. 2009,43(4):263-268.

IX. Experience requirement

For easy cases, CA is less technique sensitive compared with LA

However for difficult cases, special training and experiences are required

for the CA orthodontists, since it’s a totally different system from the fixed

appliances

✓ CA is much more difficult than it looks like

✓Individual lingual orthodontics is powerful and mature to treat almost all types of malocclusions with high efficiency, especially for the bimaxillary protrusion extraction cases

✓The treatment results for BP extraction cases using clear aligners are acceptable, though not so efficient, and this technique is evolving everyday with promising future

Summary